Scope

1. Sorgnye perspektiver på livet med dødenThe Dual Process ModelMargaret Stroebe & Henk SchutDepartment of Clinical & Health PsychologyUtrecht UniversityThe NetherlandsInvited Address to the Danish Association of Palliative CareJune 1st, 2007

2. Scope • Differences in ways of coping & adaptation • Models of coping

3. Differences in ways of coping & adaptation

4. Coping with Grief:Assumption (Western Societies)(cf. Wortman & Silver, 1987; 1989) • Necessary to confront: • Grief Work

5. Grief Work(M. Stroebe, Omega, 1992) Process of: • emotionally confronting the reality • going over events • focusing on memories • working toward detachment • “Grief work hypothesis”

6. Coping with Grief:Assumption (Western Societies)(cf. Wortman & Silver, 1987; 1989) • Necessary to confront: • Grief Work • In C20th grief theories & therapies

7. Doubts about “Grief Work” • Alternative ways of effective coping • Cultural patterning

8. Coping with Bereavement in Non-Western Cultures:Egypt In Egypt the bereaved are encouraged to dwell profusely on their subjective pain in an atmosphere where … others also immerse themselves in tragic tales and expressed sorrow. (Wikan, 1988, p. 455)

9. Coping with Bereavement in Non-Western Cultures:Bali In Bali laughter and cheerfulness fill the air while the bereaved are enjoined to contain their sorrow and may be made to feel they commit an injustice to others should they fail to abide by this demand. (Wikan, 1988, p. 455)

10. Doubts about “Grief Work” • Alternative ways of effective coping (non-confrontive) • Neglect of effortful struggle

11. Doubts about “Grief Work” • Alternative ways of effective coping (non-confrontive) • Neglect of effortful struggle • Need for “dosage” of grief

12. Doubts about “Grief Work” • Alternative ways of effective coping (non-confrontive) • Neglect of effortful struggle • Need for “dosage” of grief • Benefits of denial

13. Doubts about “Grief Work” • Alternative ways of effective coping (non-confrontive) • Neglect of effortful struggle • Need for “dosage” of grief • Benefits of denial • Other sources of stress

14. Doubts about “Grief Work” • Alternative ways of effective coping (non-confrontive) • Neglect of effortful struggle • Need for “dosage” of grief • Benefits of denial • Other sources of stress • Lack of empirical evidence

15. 1. Expression of Emotions & Well-being among Bereaved Persons(Schut, 1992, Stroebe, Schut & Stroebe, 2005) • Longitudinal study, 128 recently-bereaved • 4 assessments, 2 years • Emotional disclosure; adjustment

16. Path model of expression of emotions and distress (Schut, 1992, Stroebe, Schut & Stroebe, 2005) Expression of emotions T1 Expression of emotions T2 Expression of emotions T3 Expression of emotions T4 Distress T2 Distress T3 Distress T4 Distress T1

17. Structural path-analysis of expression of emotions and distress (Schut, 1992, Stroebe, Schut & Stroebe, 2005) .45*** Expression of emotions T1 Expression of emotions T2 Expression of emotions T3 Expression of emotions T4 .61*** .42*** .63*** Distress T2 Distress T3 Distress T4 Distress T1 .64*** .63*** .41*** .31* .17* Note: * = p<.05, ** = p<.01, *** = p<.001

18. 2. Grief Work Through Diary Writing: The Pennebaker Paradigm[e.g. Pennebaker & Keough, 1999; Pennebaker et al., 2001)

19. Pennebaker’s writing paradigm: Effects • Reduces physician consultations • Improves some immune functions • Increases grades among students • Improves mood • Effective among unemployed, prisoners, chronically-ill patients, etc. • Bereaved persons???

20. The Utrecht Diary Study(cf. Stroebe, Stroebe, Schut, Zech, & van den Bout, JCCP, 2002) • 157 recently bereaved men & women • Writing & non-writing conditions • Assessed mental & physical health (inc. visits to doctor)

21. Results Symptoms decrease over time, but: No effect of writing on: • Emotional intensity • Health (“subjective” or “objective”)

22. Conclusions so far: The grief work model needs revision to… …define when and for whom - and what type of – working through / disclosure is efficacious

23. Models of coping

24. Phase Model (Bowlby, 1980) Shock Yearning/protest Despair Restitution Task Model (Worden, 1991) Accept reality of loss Experience pain of grief Adjust to life without deceased Relocate deceased emotionally & move on Grief Work Models

25. Dual Process Model of Coping with Bereavement(Stroebe & Schut, Death Studies, 1999) A taxonomy to describe ways people come to terms with the loss of a close person: • Two categories of stressors • Analysis of coping: strategies & appraisal • Dynamic process of oscillation

26. The Dual Process Model of Coping with Bereavement Stroebe & Schut (Death Studies, 1999) Everyday life experience Loss- oriented Restoration- oriented Attending to life changes Doing new things Distraction from grief Denial/avoidance of grief New roles/ identities/ relationships Grief work Intrusion of grief letting go-continuing-relocating bonds / ties Denial/avoidance of restoration changes oscillation

27. Caregiving & Bereavement AdaptationSchulz, Boerner, & Herbert (in Stroebe et al., Handbook of Bereavement Research: 21st Century Perspectives, in press) • Caregivers at high risk • Most adapt well to bereavement • But a few have adverse bereavement outcomes

28. Phase Model (Bowlby, 1980) Shock Yearning/protest Despair Restitution Task Model (Worden, 1991) Accept reality of loss Experience pain of grief Adjust to life without deceased Relocate deceased emotionally & move on Comparison of Models DPM (Stroebe & Schut, 1999) Accept reality of loss …and accept reality of changed world. Experience pain of grief …and take time off from pain of grief. Adjust to life without deceased … and master the changed (subjective) environment. Relocate deceased emotionally & move on …and develop new roles, identities, relationships.

29. Complicated Grief • “Deviation in time course and/or intensity from the (cultural) norm”, poor functioning • Chronic; absent, delayed, inhibited • Prevalence rates • Related to other mental health difficulties • DSM??? (see Special Issue Omega, 2005, ed. Parkes)

30. DPM: Complicated Grief Everyday life experience Loss- oriented Restoration- oriented Attending to life changes Doing new things Distraction from grief Denial/avoidance of grief New roles/ identities/ relationships Grief work Intrusion of grief breaking-continuing-relocating bonds / ties Denial/avoidance of restoration changes Disturbed oscillation: Traumatic grief Absent or inhibited grief Chronic grief

31. DPM:Gender Differences

32. Gender Differences in the DPM Everyday life experience Women Men Loss- oriented Restoration- oriented Attending to life changes Doing new things Distraction from grief Denial/avoidance of grief New roles/ identities/ relationships Grief work Intrusion of grief Breaking bonds/ ties/relocation Denial/avoidance of restoration changes

33. DPM: Time

34. DPM: Time Everyday life experience Restoration- orientation Loss- orientation oscillation

35. DPM: Time Everyday life experience Restoration- orientation Loss- orientation oscillation

36. DPM: Time Everyday life experience Restoration- orientation Loss- orientation oscillation

37. DPM: Time Everyday life experience “Have I forgot, my Only Love, to love thee, Severed at last by Time’s all-wearing wave?” Emily Brönte Loss- orientation Restoration- orientation

38. DPM: Family Grief

39. DPM: Family Dynamics ♂ Restoraiton- orientation Loss- orientation Loss- orientation Restoration- orientation Loss- orientation Restoration- orientation Restoration- orientation Loss- orientation ♀

40. DPM: Family Dynamics Restoraiton- orientation Loss- orientation Loss- orientation Restoration- orientation Restoration- orientation Loss- orientation ♀

41. DPM: Family Dynamics Restoration- orientation Brother Loss- orientation Children Wife Loss- orientation Restoration- orientation Restoration- orientation Loss- orientation Grandchildren

42. DPM: Evidence • Gender differences in loss / restoration in bereaved couples • Gender differences in intervention efficacy • Intervention efficacy: DPM vs. Traditional

43. DPM: Evidence • Gender differences in loss / restoration in bereaved couples • Gender differences in intervention efficacy • Intervention efficacy: DPM vs. Traditional

44. Parental Loss of a Child Study(Wijngaards, Stroebe, Stroebe, Schut, van den Bout, van der Heijden, & Dijkstra (British Journal of Clinical Psychology, in press) Participants & Design: • 219 parental couples • 6, 13, 20 months post-loss • Interviews / questionnaires • Own and partner’s coping (DPM) & adjustment

45. Parental Loss of a Child Study(Wijngaards, Stroebe, Stroebe, Schut, van den Bout, van der Heijden, & Dijkstra (British Journal of Clinical Psychology, in press) Results: • Hi LO -> poor adjustment • Hi RO -> better • Hi RO buffered against impact of hi LO • For men, having hi RO partner helped adjustment

46. DPM: Evidence • Gender differences in loss / restoration in bereaved couples • Gender differences in intervention efficacy • Intervention efficacy: DPM vs. Traditional

47. Evaluation Of Grief Counseling: Utrecht Study(Schut, Stroebe, de Keijser & van den Bout, 1997) • Participants • Widows & widowers • Medium / high distress • Non-intervention controls • Counseling: • Client centered vs. behavior therapy • 7 sessions, 14-17 months post-loss • Measure: • General Health Questionnaire (GHQ)

48. Behav. Treatment Client centered Schut, Stroebe, avan den Bout & de Keijser (1997) British Journal of Clinical Psychology

49. Levels of Distress by Therapy Type: Males(Schut, Stroebe, de Keijser, & van den Bout, BJCP, 1997)

50. Levels of Distress by Therapy Type: Females(Schut, Stroebe, de Keijser, & van den Bout, BJCP, 1997)